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Preface
ix
D-dimer can be useful adjuncts in making the diagnosis of DVT, although this
is not as sensitive or specific for the disease as duplex ultrasonography.
The goal of DVT treatment is to reduce the risk of PE, decrease extension
of DVT, and prevent the almost 30% recurrence rate of an untreated DVT.
Systemic anticoagulation is the mainstay of treatment in patients diagnosed
with DVT and PE. Catheter directed pharmacologic thrombolysis is another
option that is thought to preserve valve function. Inferior vena cava (IVC)
filter placement is another aspect of DVT treatment.
Chapter 4 – Superficial thrombophlebitis is defined as inflammation and
thrombosis of a vein near the skin‟s surface. Most studies underestimate the
occurrence of superficial thormbophlebitis and although the greater or lesser
saphenous veins are the most commonly affected veins, this disease can occur
at any part of the body.
This condition is often associated with a long term intravenous (IV)
catheter and is differentiated from septic thrombophlebitis by the absence of
systemic signs of infection. Risk factors include recent venous catheterization,
a history of previous superficial venous thrombosis, DVT or PE, recent
surgery, trauma, pregnancy, high dose estrogen therapy, immobilization,
malignancy, varicose veins, obesity, or intravenous drug abuse.
Superficial thrombophlebitis remains a clinical diagnosis. Symptoms
include localized pain and warmth over the site and patients will present with
tenderness to palpation, induration, and erythema over a palpable cord. It is
noted that superficial thrombophlebitis coexists with DVT in up to 53% of
cases and PE in up to 33% of cases. Superficial thrombo-phlebitis can progress
rapidly to venous thromboembolism (VTE) in as much as 15% of cases.
Even though most times superficial thrombophlebitis will resolve on its
own, it is not considered to be self limited and complications can occur. These
include extension from a superficial vein to a deep vein, postphlebitic
syndrome, chronic DVTs, suppurative thrombophlebilitis and septic
thrombophlebitis.
The aim of treatment is to alleviate symptoms and prevent extension to
deep veins. The mainstay of treatment consists of extremity elevation, warm
compresses, and the use of non-steroidal anti-inflammatory drugs (NSAID).
Most patients respond to this conservative management regime with symptom
resolution or improvement in 7-10 days. There is some evidence that shows
the use of subtherapeutic doses of low molecular weight heparin can help in
prevention of extension of superficial thrombophlebitis to DVT but there are
no large multicenter trials to support this and make it standard of care.
https://t.me/med1917
Caroline H. Gutmann
x
Chapter 5 – Thrombophilias can be defined as a group of inherited or
acquired disorders that increase the risk of developing thrombosis. Venous
thromboembolism (VT) is considered a multifactorial disease produced by a
sum of risk factors that predispose to the thrombotic event. This predisposition
includes genetic and acquired defects. VT is one of the major public health
problems worldwide, contributing to an estimated >500,000 deaths in Europe
each year, with a mortality rate of 10%. The risk of recurrence is about 6% per
year, and post-thrombotic disease occurs within the next 5 years following a
VT event in about 25% of patients. VT is a common multifactorial disease,
with both established environmental and genetic risk factors.
The genetic basis of the VT is only partially known, and thrombophilia
can only explain around 50% of the thrombotic events. Hence, the known risk
factors, together with yet unknown alterations in any component of the
haemostatic system, may allow us to further clarify the underlying mechanism
of VT. The known genetic risk factors confer a poor relative VT risk,
altogether can only explain about 5% of the VT heritability.
The identification of disease-associated VT genes suspected to be
involved in the physiopathology of the disease could help to define its genetic
determinants.
Moreover, the recent availability of high-throughput genotyping
technologies and their application in the framework of genome-wide
association studies (GWAS) have enabled the identification of novel
susceptibility loci. From 1965 to 2013, 16 genes/loci have been robustly
associated with the susceptibility to VT, most of them affecting the
coagulation cascade. In addition to the well-known established susceptibility
genes for VT: F5, F2, FGG, PROC, PROS, SERPINC1, and ABO blood
group, new emerging susceptibility loci have arisen: C4BPA/C4BPB, F11,
G6P, HIVEP1, KNG1, STXBP5, TCN2, VWF. However, independent case-
control studies are needed to confirm the association with the disease for these
emerging genes. This chapter summarizes the current information on the role
of genetic risk factors for venous thrombosis.
Chapter 6 – The annual incidence of venous thrombosis varies from 40 per
100,000 to 250 per 100,000 in different populations. Thrombosis can occur in
any section of the venous system, but commonly manifests as deep vein
thrombosis of the leg and pulmonary embolism. Major complications of
venous thrombosis are a disabling post-thrombotic syndrome, pulmonary
hypertension, and sudden death duo to a pulmonary embolism and therefore, it
poses a burden on health economy. Venous thrombosis is a common clinical
challenge for doctors of all disciplines, as it is a complex multicausal disease.
https://t.me/med1917
Preface
xi
Hereditary conditions account for ~60% of all the thrombosis incidents and a
number of genetic risk factors have been identified so far. Acquired risk
factors may contribute to variations within and between individuals. Diagnosis
of thrombosis is not difficult with the development of imaging techniques.
However, the most important steps for diagnosis are etiology analyzes and
genetic tests, which are useful for assessments of duration of anticoagulant
therapy and prevention for thrombosis.
Chapter 7 – Thrombotic diseases develop as the result of multiple
interactions between non-genetic and genetic risk factors. The known
atherogenic risk factors played an important role as predictors in the
development of the thrombotic diseases in the present female case-control
study. The most important non-genetic risk factors found among the female
patients are: age, hypercholesterolemia, DM, use of oral contraception,
obesity, and fibrinogen levels. Moreover, the stratified effect of some of these
factors according to the age of the patients is relevant for clinical risk
assessment. Associations between the risk of venous thrombosis (VT) and
genetic polymorphisms have been established. Some of these polymorphisms
are highly prevalent in Caucasians, but there is a significant geographic
variation in their prevalence among different populations. The MTHFR C677T
(rs1801133), are analyses in females with stroke, venous thrombosis and
myocardial infarction in a case-control study. The C677TMTHFR mutation
were detected in 149 patients and 113 controls (P=0,001). In the present study,
the results showed that hypercholesterolemia, diabetes mellitus, and elevated
levels of fibrinogen were present in the younger group as risks factors. Family
history of thrombotic event (TE) was statistically significantly associated
among the older female group. Median values of total fibrinogen were
significantly higher in the cases compared with the control group. The small
numbers of carriers of these risk factors require a note of caution on any
conclusion. The present data suggest that MTHFR C677T genotype may be an
important factor in the life of female patients at risk of developing TE or
cardiovascular disease , p=0,001 between cases and controls groups . Folic
acid supplementation of foods is necessary (and mandatory in Costa Rica)
before and during women‟s reproductive phase. However, our data presented
suggest that a case for efforts to ensure a good intake of this vitamin in the
postmenopausal phase. Especially if the high prevalence of the MTHFR 677T
homozygosity and of classic risk factors in the Costa Rican population are
taken into account. Further studies with more patients are necessary for final
conclusions for these interactions to be drawn.
https://t.me/med1917
Caroline H. Gutmann
xii
Chapter 8 - Cerebral Venous thrombosis (CVT) accounts for nearly 1-2%
of all strokes. Isolated cortical vein thrombosis (ICVT), a subtype of CVT,
without sinus or great venous involvement is rare. It is often difficult to
diagnose due to its varied clinical and imaging features. Hence, the available
literature largely comprises of single center case series. The common
presenting symptoms of ICVT are focal seizures, vaguely defined focal
neurological deficits and visual disturbances. Headache and raised intracranial
pressure are relatively uncommon. The underlying conditions which may
predispose to ICVT are the same as described for typical CVT. However, rare
associations of ICVT include lumbar puncture, Hodgkin‟s disease, nephrotic
syndrome, vasculitis, inflammatory bowel disease and amyloid angiopathy.
With a high index of suspicion, neuroimaging is essential for direct
visualization of the thrombus, localized hemorrhage or small venous
infarction. Visualization of thrombosed cortical vein (the cord sign) is
observed infrequently. Management guidelines are not well established.
However, initial anticoagulation with heparin followed by oral anticoagulation
for 6-12 months remains the recommended guideline for treatment of ICVT.
The prognosis is generally good with radiological resolution in most cases. In
this review, we present the clinical spectra, etiopathogenesis, neuroimaging
features and management options in ICVT patients.
https://t.me/med1917
In: Venous Thrombosis ISBN: 978-1-63117-293-9
Editor: Caroline H. Gutmann © 2014 Nova Science Publishers, Inc.
Chapter 1
Venous Thromboembolism
in Oncologic and Reconstructive
Breast Surgery
Solmaz Niknam Leilabadi, M.D., M.H.A.,
Hyuma A. Leland, M.D., Vinaya Soundararajan, B.S.
and Alex K. Wong, M.D., F.A.C.S.
Division of Plastic and Reconstructive Surgery, Department of Surgery,
Keck School of Medicine of USC, Los Angeles, CA, US
Abstract
Breast cancer is the most common malignancy in females, after skin
cancer, with lifetime incidence of 12.4% and the second most common
cause of cancer related deaths among women. Venous thromboembolic
(VTE) events have been found to affect 0.16 to 2.3% of breast cancer
patients and are associated with increased mortality. Nearly all breast
cancer patients require mastectomy or lumpectomy as part of the
treatment regimen and many of these patients also undergo
reconstruction, either immediate or delayed. Risk factors associated with
VTE include advanced cancer stage, prolonged operative time, inpatient
hospitalization, immediate reconstruction, chronic medical comorbidities,
venous catheterization, age, obesity, and tamoxifen or chemotherapy use.
corresponding author, email: alex.wong@med.usc.edu.
https://t.me/med1917
Solmaz Niknam Leilabadi, Hyuma Leland, Vinaya Soundararajan et al.
2
This chapter will focus on VTE complications that arise from surgical
treatment, mastectomy, and breast reconstruction, in breast cancer
patients. Identifying risk factors will help guide physicians to improved
prevention practices and hopefully a standardized VTE prophylaxis
protocol for breast cancer patients.
Introduction
Venous thromboembolism (VTE) occurs rarely, but when unrecognized it
can lead to significant morbidity and mortality. VTE encompasses both
pulmonary embolism (PE) and deep vein thrombosis (DVT). Acute mortality
from VTE is the result of embolic migration of a DVT into the pulmonary
artery. In the general population, age-adjusted incidence of VTE is
approximately 1 in 1000 people. [1] In cancer patients, this risk can be
increased up to seven-fold, depending on the type of cancer. [1] VTE is
preventable if high risk individuals are given prophylactic anti-coagulation.
Breast cancer is the most common form of cancer, aside from skin cancer,
in women, occurring in 1 out of 8 women in the United States. [2] A review of
the literature indicates that the risk of VTE in breast cancer ranges from 0.16
to 2.3%. Interestingly, while the incidence of VTE in breast cancer is lower
than other forms of cancer, those who actually develop VTE in this setting
have a very high mortality rate. [1,3] In fact, circulatory system disease,
including VTE, is the second most common cause of death in breast cancer
patients, following cancer itself. [4] Patients may also develop chronic
symptoms from VTE, such as severe pain, edema, ulceration, post-phlebitic
syndrome, and chronic thromboembolic pulmonary hypertension, leading to
significant morbidity and decreas ed quality of life.
Until recently, the low incidence of VTE in breast cancer precluded
researchers from understanding more about the disease. However, the
development of regional and national registries and databases has given new
insight into the disease process and risk factors for VTE in breast cancer
patients. Because VTE is a preventable complication that has significant, life-
threatening consequences, it is important to determine the risk factors and
establish a standardized protocol for prophylaxis. Breast cancer treatments,
including chemotherapy, hormonal therapy, radiotherapy, the placement of
central venous catheters, and surgery itself greatly increase the likelihood of
developing VTE. [5] To reduce this risk, some physicians have integrated
routine use of pharmacologic anticoagulant prophylaxis, graded anti-
https://t.me/med1917
Venous Thromboembolism in Oncologic …
3
thrombotic elastic compression stockings, and intermittent pneumatic
compression devices into their practice. [5] Early ambulation and mechanical
prophylaxis have shown to be best methods of VTE prevention for the
majority of low risk breast cancer patients. [6]
This chapter will focus on VTE complications that arise from mastectomy
and breast reconstruction in breast cancer patients. Identifying risk factors will
help guide physicians to improved prevention practices and hopefully a
standardized VTE prophylaxis protocol for breast cancer patients.
Venous Thromboembolism
in Mastectomy Patients
The incidence of VTE in breast cancer patients ranges from 0.16-2.3%,
[3,5] which is low compared to other malignancies; however, the high
incidence of breast cancer translates to nearly 5,300 cases of VTE per year in
U.S. breast cancer patients alone. VTE is a poor prognostic factor, correlating
with worse overall survival and disease specific survival, in age, cancer type,
stage, and surgical procedure matched patients. [7] In one series of 89 patients
who underwent a modified radical mastectomy, two out of the five patients
who developed a DVT also developed a PE, one of which died. [8] This
increased mortality finding was also supported in a review of over 108,000
breast cancer patients that demonstrated a 2.3-fold increased risk of death over
two years in breast cancer patients with VTE. [9] The American College of
Chest Physicians (ACCP) publishes comprehensive evidence based clinical
practice guidelines for antithrombotic therapy and prevention of thrombosis in
medical and surgical patients. [10] The guidelines for general and abdominal
surgery patients are summarized in Table 1; however, there are no evidence-
based guidelines specifically for plastic and reconstructive surgery patients as
there is a lack of randomized trials investigating VTE in these patients.
10
Clinically, despite well reported increased risk and associated mortality in
breast cancer patients with VTE, a survey of over 600 reconstructive breast
surgeons revealed only 25% of surgeons reported compliance with the ACCP
guidelines on thromboprophylaxis. [11] Failure to meet the standard of care in
VTE prevention has reinforced the need for all surgeons to assess whether
VTE prophylaxis is indicated on a per patient basis. The Caprini risk
assessment model (RAM), along with recent studies that improve our
https://t.me/med1917
Solmaz Niknam Leilabadi, Hyuma Leland, Vinaya Soundararajan et al.
4
recognition of risk factors that confer greater risk of VTE in breast cancer
patients, can help guide the decision to initiate VTE prophylaxis.
Table 1. Summary of ACCP recommendations for patients
undergoing general or abdominal-pelvic surgeries.
Recommendations compiled from American College
of Chest Physicians recommendations. [10]
Level of risk for VTE
Recommendation
Very low risk (Caprini Score 0)
No specific pharmacologic or mechanical
prophylaxis other than early ambulation
Low risk (Caprini score 1-2)
Mechanical prophylaxis, preferably IPC,
over no prophylaxis
Moderate risk (Caprini score 3-4) who are
NOT at high risk for major bleeding
complication
LMWH, low dose UH, or mechanical
prophylaxis, preferably IPC, over no
prophylaxis
Moderate risk (Caprini score 3-4) who are
at high risk for major bleeding
complication or those in whom the
consequences of bleeding are thought to
be particularly severe
Mechanical prophylaxis, preferably IPC,
over no prophylaxis
High risk (Caprini score 5) who are
NOT at high risk for major bleeding
complication
LMWH or low dose UH over no
prophylaxis, suggest mechanical
prophylaxis with elastic stockings or IPC
should be added to pharmacologic
prophylaxis
High risk undergoing abdominal or pelvic
surgery for cancer who are not otherwise
at high risk for major bleeding
complications
Extended-duration pharmacologic
prophylaxis (4 weeks) with LMWH over
limited-duration prophylaxis
High risk undergoing abdominal or pelvic
surgery who are at high risk for major
bleeding complication or those in whom
the consequences of bleeding are thought
to be particularly severe
Mechanical prophylaxis, preferably IPC,
over no prophylaxis until risk of bleeding
diminishes and pharmacologic prophylaxis
may be initiated
High risk in whom both LMWH and UH
are contraindicated or unavailable and
who are not at high risk for major
bleeding complications
Low-dose aspirin, fondaparinux, or
mechanical prophylaxis, preferably IPC,
over no prophylaxis
LMWH = low molecular weight heparin, UH = unfractionated heparin,
IPC = intermittent pneumatic compression
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Venous Thromboembolism in Oncologic …
5
Caprini Risk Assessment Model
The Caprini RAM was developed in an effort to risk stratify medical and
surgical patients based on risk factors derived from clinical experience and
published data. Several iterations of the Caprini RAM have emerged since it
was first reported in 1991, [12] and recently, the 2005 Caprini RAM (Figure 1)
was found to most accurately risk stratify plastic and reconstructive surgery
patients. [12] The Caprini RAM has been validated in a variety of patient
populations, including plastic and reconstructive surgery, [13] general surgery,
urology, otolaryngology, [14] vascular surgery, and medical inpatients [15].
The Caprini score is calculated by assessing a point value to VTE risk
factors in general categories of age, obesity, surgical operation, medical
comorbidities, mobility, and hereditary risk. Point values are then stratified by
range into very low, low, moderate, high, and super-high risk. Until 2012,
ACCP guidelines did not make recommendations on plastic and reconstructive
surgery patients and currently do not specifically address breast surgery.
Therefore, consensus guidelines presented herein are based on the 2011
American Society of Plastic Surgery (ASPS) VTE Task Force, which
specifically addresses VTE prophylaxis recommendations for plastic and
reconstructive surgery patients.
The ASPS VTE Task Force recommends all inpatients undergoing surgery
under general anesthesia be assessed by the Caprini RAM or an equivalent
RAM. Physicians should also consider whether outpatients undergoing general
anesthesia should also be assessed. While ASPS does not specifically give
recommendations on very low and low risk patients, ACCP [16] and leaders in
VTE risk assessment modeling, including Caprini [17] and Pannucci, [13]
have recommended early ambulation for patients with a Caprini score of zero,
and intermittent pneumatic compression (IPC) for patients with a Caprini score
of 1-2. Low risk patients have approximately a 1.5% risk of VTE over 60 days
without any chemical prophylaxis. In moderate and high risk patients with a
Caprini score of 3-6, ASPS recommends low molecular weight heparin
(LMWH) or unfractionated heparin (UH) if not contraindicated by bleeding
risk. Additionally, patients should receive concomitant IPC, as it has been
shown to synergistically enhance VTE chemical prophylaxis. [18,19]
Pannucci, et al., [20] have reported that super-high risk patients with a Caprini
score over 8 have a VTE risk of 11.3% over 60 days, without perioperative
administration of pharmacologic VTE prophylaxis. Therefore, ASPS VTE
Task Force guidelines recommend LMWH or UH administration for 4 weeks
after surgery when the Caprini score is greater than 7.
https://t.me/med1917
Solmaz Niknam Leilabadi, Hyuma Leland, Vinaya Soundararajan et al.
6
Figure 1. The 2005 Caprini Risk Assessment Model. Reprinted from Disease-a-Month,
51, Caprini JA, Thrombosis Risk Assessment as a Guide to Quality Patient Care, 70-
78., Copyright 2005, with permission from Elsevier.
Effectiveness of Chemical Thromboprophylaxis
The efficacy of chemical VTE prophylaxis has been widely reported in
patients undergoing colectomy, [21] orthopedic hip surgery, [22]
chemotherapy for pancreatic cancer, [23] ambulatory chemotherapy, [24] and
medically ill patients. [25] In plastic and reconstructive surgery patients, a
multicenter trial of 1,458 patients at moderate to high risk for VTE, defined by
a Caprini score of 3, were treated only postoperatively with LMWH for the
duration of their hospital stay. [26] This group was then compared against
1,876 historical control patients for the primary endpoint of symptomatic VTE
reduction. [26] In patients with a Caprini score > 8, untreated patients
developed symptomatic VTE at a rate over 8.5%. Comparatively, patients with
https://t.me/med1917
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